Registration form

Cycle for Art
A charity cycling event for the
South Shore Health Services Foundation

Saturday September 12, 2015

NAME : __________________________________________
(please include middle initial)

ADDRESS: ________________________________________

TOWN: ___________________________________________

PROVINCE: ________________________________________

POSTAL CODE: ____________________

PHONE : __________________________

DISTANCE : o 25K o 50K o100K

DISCLAIMER - I, for myself, my heirs, my executors, administrators and assigns do hereby release
and discharge the Health Services Foundation of the South Shore, all sponsors, event organizers
and volunteers for all damages, demands, actions, and anything in any manner arising from my
participation in the Cycle for Art cycling event.

DATE: ___________________________

SIGNATURE: _____________________
(if age 18 or under, signature of parent/guardian)

Parent: __________________________

(entry fees are non-refundable)

Cycleforart is an event by the Health Services Foundation of the South Shore

This page was updated on : July 22, 2015
(C) 2015

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